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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review processes, ensuring compliance with URAC, ERISA, and other regulatory requirements while maintaining high standards of patient care. Proficient in medical terminology, coding certifications, and effective communication with healthcare providers.
Highest-signal resume keywords
Utilization ReviewRegistered NurseOASIS Coding CertificationMedical TerminologyCompliance with ERISA
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewMedical Necessity EvaluationPeer Review ReportingCoding CertificationPatient Care ExperienceKnowledge of Anatomy and PhysiologyTreatment ProtocolsLaboratory ValuesTyping Speed of 40 W.P.M.Confidentiality Maintenance
Soft Skills
Ability to Work IndependentlyTime ManagementAbility to Work Under PressurePrioritization SkillsCustomer Service
Tools & Technologies
Microsoft SuiteDatabase ManagementGeneral Computer OperationFax MachineCopierScannerTelephone
Certifications & Qualifications
Registered NurseLicensed Practical NurseLicensed Vocational NurseOASIS Coding CertificationRAC-CTCCSCPCRHITRHIACPMA (Preferred)
Industry Keywords
URACERISAUtilization ManagementQuality AssuranceEvidence-Based GuidelinesHealthcare CompliancePatient Care StandardsRegulatory RequirementsDetermination LettersClient Complaints
About the role
Key responsibilities & impact- Perform quality utilization reviews using evidence-based guidelines
- Approve medically necessary and appropriate care
- Prepare peer review reports, correspondence, addendums, and supplemental reviews
- Work directly with providers to identify the level, intensity, and duration of care
- Evaluate medical necessity for frequency, intensity, and length of required care
- Ensure reviews meet industry quality standards and mandated turnaround times
- Maintain knowledge of URAC and state and federal regulatory requirements
- Maintain accurate utilization review records in the appropriate database
- Direct Customer Service Representatives to ensure timely delivery of determination letters
- Assist with client complaints and quality assurance issues
- Ensure compliance with ERISA, URAC, and other applicable guidelines
- Provide management with insight on compliance concerns
- Participate in company meetings, training activities, and continuing education
- Perform other assigned duties
Requirements
What you’ll need- High school diploma or equivalent required
- Graduate of an accredited nursing program
- Active unencumbered Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse required
- Current coding certification in OASIS, RAC-CT, CCS, CPC, RHIT, or RHIA required
- CPMA certification preferred
- Three to five years of direct professional patient care required
- Experience in utilization management preferred
- Strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications, and laboratory values
- Qualified typist with a minimum of 40 W.P.M.
- Ability to operate a general computer, fax, copier, scanner, and telephone
- Knowledge of Microsoft Suite and multiple software programs
- Ability to maintain confidentiality
- Ability to work independently, prioritize work, and use time efficiently
- Ability to work under pressure and manage interruptions or unexpected events
- Ability to follow company policies and procedures
Benefits
Comp & perks- Medical insurance
- Vision insurance
- Dental insurance
- Paid time off
- 401k
- Continuing education requirements
- Company meetings and training activities
- Fully remote work
- Competitive benefits